Suicide and self-harm in adult survivors of critical illness: population based cohort study

BMJ. 2021 May 5:373:n973. doi: 10.1136/bmj.n973.


Objective: To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge.

Design: Population based cohort study using linked and validated provincial databases.

Setting: Ontario, Canada between January 2009 and December 2017 (inclusive).

Participants: Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period.

Main outcome measures: The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models.

Results: 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56).

Conclusions: Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Case-Control Studies
  • Critical Care
  • Critical Illness / psychology*
  • Critical Illness / therapy
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Ontario / epidemiology
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • Self-Injurious Behavior / diagnosis
  • Self-Injurious Behavior / epidemiology
  • Self-Injurious Behavior / etiology*
  • Self-Injurious Behavior / psychology
  • Suicide / psychology
  • Suicide / statistics & numerical data
  • Survivors / psychology*
  • Young Adult